Provider Demographics
NPI:1932489499
Name:FAKEYE, LATRELLE A (RPH)
Entity Type:Individual
Prefix:MS
First Name:LATRELLE
Middle Name:A
Last Name:FAKEYE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LAKE EMERALD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8407
Mailing Address - Country:US
Mailing Address - Phone:386-847-9343
Mailing Address - Fax:386-740-0112
Practice Address - Street 1:2400 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-8636
Practice Address - Country:US
Practice Address - Phone:386-822-4503
Practice Address - Fax:386-740-0112
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist